On their first day, I tell my junior medical students, who are beginning their psychiatry clerkship at our borderline personality disorder treatment program, that no matter what field of medicine they choose, they will have patients with personality disorders. Borderline personality disorder (BPD), which is prevalent in mental health settings (approximately 15–25%), also appears to be highly represented in nonpsychiatric settings.[1] I also tell my beginning students that providing medical and surgical care for patients with BPD often will be challenging. Indeed, these patients are at risk of engaging in medically self-sabotaging behaviors, such as intentionally interfering with wound healing, misusing prescribed medication, or exposing themselves to infection, among others. In addition, BPD patients have been shown to have higher rates of somatic symptom preoccupation, persistently reporting the experience of multiple diffuse physical complaints, and they demonstrate elevated rates of complex conditions,[2] such as psychophysiological disorders (i.e., fibromyalgia, migraine), chronic pain syndromes, and obesity. They even may be more prone to having adverse drug reactions.

Multiple studies conducted by Sansone and Sansone, along with several multidisciplinary collaborators, have played an ongoing central role in empirically revealing these observations about BPD in medical settings. These authors have compiled their impressive body of research, much of the other work in this area, and their hard-earned clinical wisdom into an interesting and accessible book, Borderline Personality Disorder in the Medical Setting: Unmasking and Managing the Difficult Patient, which will be helpful for psychiatric and medical practitioners alike.

In the Introduction to this volume, Drs. Sansone explain their choice of title, contending that BPD psychopathology frequently lies “behind the mask” of the often deemed “difficult patient” in medical settings. “Unmasking” this psychiatric diagnosis is an essential first step for lessening this management difficulty. The book’s first section (of three) contains a psychiatric overview of BPD, emphasizing the clinical “paradox” of an intact social façade coupled with core level chronic self-regulation impairment and self-harm inclinations. Clinicians are alerted that physically symptomatic BPD patients may look much more mentally healthy than they really are. This overview is not solely descriptive, nor does it veer into complex theoretical explanations which necessitate prior readings. Six understandable psychological themes in BPD are presented, and, importantly, the reader is explicitly guided in recognizing BPD phenomena within the diagnostic limits of a busy medical clinic.

The next section characterizes BPD in the medical setting, including the challenging general medical issues, namely somatic symptom preoccupation and medical self-sabotage, and the common comorbid syndromes, such as chronic pain, psychophysiological disorders, and obesity. In this section, the authors propose that BPD development theoretically may “bifurcate” to either a predominantly psychiatric or predominantly somatic presentation based on a number of mediating factors, such as the valuing of physical problems over emotional problems in one’s early environment. The authors acknowledge that this intriguing theory awaits empirical exploration.

The volume’s final section discusses what to actually do when caring for an “unmasked” BPD patient in the medical setting. First, several “mantras” are elaborated, which are broad philosophical ideas about BPD and medical care. I expect that clinicians who internalize these mantras will come away with an invaluable “gut level” sense that they are on firm ground in attempting to do the right thing with their difficult cases.

Accordingly, the book can serve as an invaluable confidence-maintaining companion to repeatedly return to during long and fluctuating treatment courses with BPD patients. Two standout empowering mantras include the notion that even the most expert clinician cannot effectively treat every BPD patient that he or she encounters, and the fact that patient dissatisfaction and complaints are very likely when necessary limits are upheld.

The second part of this section describes a number of practical techniques for managing BPD in the medical setting. These highly applicable techniques are consistently illustrated in actual clinical scripts. Along the way, readers will likely experience some knowing amusement with these scripts when, for instance, a representative patient (page 107) states “Hey, doc! Thanks for getting me in on such short notice! I’m out of everything! I ain’t got no meds left! I need my Vicodin, Klonipin, and Duragesic patches!” This part of the book includes summary “practice points,” which are condensed recommendations that also can be returned to repeatedly for valuable reference. The last chapter, which discusses BPD psychopharmacology, prominently embodies a core message of the entire volume, which is that medical clinicians must constantly strive to “Do No Harm” to these maltreatment (victimization)-prone individuals.

“Do No Harm” is, in fact, one of the management mantras, and it underlies the specific recommendation that BPD patients’ medical treatment should be approached quite conservatively. The authors notably contend that patients with BPD cannot psychologically heal in medical settings, but can only receive effective medical treatment. Such patients, however, can be harmed in medical settings. This harm is not only physical in the form of invasive tests, disfiguring surgeries, and drug side effects; it is also psychological, stemming from the anger, condemnation, invalidation, and/or abandonment that BPD patients receive from understandably frustrated, confused, or possibly frightened clinicians. These reactions can reinforce their psychopathology.

My only criticism is already acknowledged by the authors (page 113). Specifically, there is no prospective intervention research testing whether their seemingly theoretically sound and experience-based management approaches to BPD in medical settings lead to better psychological and medical outcomes, less adverse events, improved patient-clinician relationships, and/or more cost-effective care. One can envision such intervention studies with BPD patients in the medical setting utilizing the content of this book as an experimental treatment manual.

Book Stats

Title
Borderline Personality Disorder in the Medical Setting: Unmasking and Managing the Difficult Patient